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Although substance abuse affects the family, the children of substance abusers suffer the most. When parents are unable to care for their children because of their untreated addiction, the children are at risk for social and health problems that include alcohol and drug use, delinquency, depression, and poor school performance. One approach to supporting families with substance abuse problems involves fostering and establishing collaborative relationships with agencies responsible for child welfare, social services, prevention programs, and mental health organizations. This action kit provides resources and action steps that can be taken to start or further efforts to raise awareness in a community about the effects of substance abuse. It suggests ways to create linkages between the child welfare system and substance abuse prevention and treatment systems. Successful community interventions are described to provide ideas on how to solve problems. A list is included of organizations that treat parents with substance abuse problems and addictions. (JDM)

Although heroin use has decreased in the general population during the last few years, a troubling new trend is emerging. Use is up among school-age children and they are now subject to a popular culture in music and films that glamorizes its use. This trend along with increased availability and purity of heroin has created a major health concern for mental health workers and educators. This publication aims to present the latest research findings about heroin abuse and addiction. It explains about the known health repercussions that extend beyond the user. The health and social consequences of drug abuse in family, educational, and work environments have a devastating impact on society and cost billions of dollars. On a hopeful note, treatment for opiate addiction is more available and is becoming more effective. This publication provides information and guidance for health workers and educators in their preventive efforts in drug education. (Contains 24 references.) (JDM)

This paper was developed as a result of a 1999 conference on substance abuse and learning disabilities. An introductory chapter urges early identification of learning disabilities and appropriate treatment for both problems when they co-exist. The second chapter discusses the differences between learning disabilities and behavioral disorders, the size of the problem of substance abuse in this population, financial and social costs to society, and possible negative outcomes of unnecessary drug treatment of children with learning disabilities. The third chapter examines the question of whether substance abuse leads to learning disabilities and/or behavioral disorders or the reverse. Evidence for the following three theories is reviewed: (1) behavioral effects of learning disabilities are also risk factors for substance abuse; (2) learning disabled children turn to drugs for self medication; and (3) children on psychoactive medication are more likely to believe in the positive effects of drugs. Also examined are the possibilities that behavioral disorders among children lead to parental substance abuse and that learning disabilities and substance abuse are the result of a common cause. The paper urges research with refined diagnostic criteria and greater efforts to inform parents, physicians, teachers, and treatment providers. (Contains approximately 210 references and 101 notes.) (DB)

A national representative survey of primary care physicians (N=648) was conducted to determine how they deal with patients who have substance abuse problems. The survey revealed how physicians identify substance abuse in their patients, what efforts they make to help these patients, and what barriers they find to effective diagnosis and treatment. The most troubling finding of the survey was that 94 percent of the physicians failed to include substance abuse among the five diagnoses they offered when presented with early symptoms of alcohol abuse in an adult patient. Also surveyed were 510 adults currently receiving treatment for substance abuse. Most patients said their physicians did nothing about their substance abuse. These findings add up to an enormous lost opportunity. Substance abuse and addiction are the leading cause of death, disability, and disease in the United States. Primary care physicians have a unique opportunity to intervene to avoid these consequences. To avoid the missed opportunity, this report recommends that medical schools increase training in substance abuse, that primary care physicians screen patients for substance abuse, and that insurers provide for physicians talking to patients about substance abuse. (Contains 3 appendixes, 27 figures, and 30 references.) (JDM)

Hong Kong's Department of Information Services has been producing and systematically airing public service announcements (known as announcements in the public interest, or APIs) on a variety of selected themes such as cleaning up Hong Kong, road safety, crime, drugs, and health issues for over 20 years. The television announcements are shown every day during mandatory time slots within every prime time commercial break period. These announcements represent the most important means by which the Hong Kong government has consistently communicated directly to the public. In carrying out their task of encouraging citizen cooperation with anti-drug efforts, the APIs produce particular characterizations of drug users, potential drug users, and families of those who use drugs. These characterizations are central to the ability of APIs to engage members of their audience and work persuasively. This paper traces the development of depictions of the drug addict in Hong Kong's anti-drug API campaign from its inception in 1976 to the present, illustrating various stages of alteration that this image has undergone. The paper argues that the depiction of drug addicts in the earlier examples was very similar to the historically shameful image of the opium addict, which had been widely circulated throughout earlier decades of the 20th century. It finds that later announcements that make use of other visual and persuasive strategies such as metaphors and testimonials (which allow for some discussion of physical and health effects) do not directly call to mind the history of opium use by the Chinese. Contains 13 references and 2 illustrations. (NKA)

The idea of specialized treatment for chemically dependent women is a relatively new notion, and professionals charged with the responsibility of treating these individuals will find little in the way of empirical guidance. In this study a number of personal variables were assessed for their potential effect on the length of sobriety for women addicts in long-term, intensive, residential treatment. It was questioned how treatment programs can address the special needs of women in treatment in order to increase the likelihood of long-term sobriety. Participants consisted of 95 clients who received chemical dependency treatment in a long-term treatment program over a 4-year period. Clients were classified into three groups based on length of sobriety. Categorical data were accumulated for 16 personal-predictor variables and then analyzed for their association with length of sobriety. Two single predictor variables, support group experience and income source, were positively associated with long-term sobriety. A third variable, abuse history, was negatively associated with sobriety. The conclusion is made that the ultimate goal of all agencies is to provide the most appropriate treatment to each client. (Contains 1 table, 1 appendix, and 35 references.) (JDM)

This report provides an overview of chemical dependency, communication barriers, and assessment/treatment considerations for individuals who are deaf or have hearing impairments and have drug or alcohol problems. Following a discussion of the pattern of substance abuse, risk factors, and signs and symptoms, the report describes a model treatment program: the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals. The following recommendations for treatment are made: (1) accessible Twelve Step groups are needed; (2) education/prevention services should be provided to individuals who are deaf or hard of hearing of all ages; (3) there is a need for accessible outpatient, inpatient, and after care services; (4) training opportunities about specialized treatment considerations should be offered to professionals working in the field of chemical dependency; (5) more interpreter training programs are needed that offer specialized training in the area of chemical dependency; (6) more chemical dependency counselors are needed who are fluent in American Sign Language; (7) additional research is needed in the prevalence of chemical dependency within the Deaf community; and (8) vocational rehabilitation counselors are needed to work closely with chemical dependency treatment programs. (Contains 13 references.) (CR)

La Casita is a culturally relevant 6-month residential substance abuse treatment program in southeast Los Angeles County (California) for low income Latina women. Most participants are second and third generation Latinas who clearly identify themselves as being Hispanic but behave in a bicultural manner. The average La Casita resident is 30 years old and has 2.5 children. Latino values form the cornerstone of programming at La Casita, with familismo, a strong identification with and attachment to the extended family, being central. Other values include collectivism and reciprocity, lineality and "Power Distance" (social support of power differentials), simpatia, and present-time orientation. The La Casita program is based both on the traditional Social Model and 12-Step approaches to residential treatment and on Latino values, which are highly consistent with traditional chemical dependency treatment programming. Women are screened for parenting stress upon entering and identified for parenting interventions when appropriate. Women are assessed upon entering the program, exiting the program, and 6 months and 1 year following exit. Approximately half the women who enter La Casita graduate. Parenting stress is the major factor in leaving. Fifty-eight women have graduated from the program; of these, 80 percent were clean and sober 12 months following graduation. Two appendices depict percentages of La Casita graduates clean and sober, and ratio of program completers to dropouts, transfers, discharges, and those who could not reunify with their child. English and Spanish versions of a measure of individual risk and protective factors for recovering Latina mothers are included. (Contains 18 references.) (TD)

The Addiction Severity Index (ASI), used throughout the United States and other countries, is the most widely used assessment tool in the addictions field. It is a semi-structured assessment instrument designed for use with clients for substance abuse treatment. The ASI gathers information in seven important areas of a patient's life: medical, employment/support, drug and alcohol use, legal, family history, family/social relationships, and psychological problems. The ASI not only assesses drug and alcohol abuse, it also screens for problems in other areas, such as mental illness. Interviewer severity ratings indicate a client's unmet need for treatment. The ASI has been shown to be reliable and valid, but this applies only with "majority" populations. When substance abuse treatment directors at the North Dakota State Hospital realized that the cultural differences, background, and religious practices of Native Americans in their state (Chippewa and Sioux) were not being adequately addressed, the ASI, already required for use in North Dakota, was modified to address Native cultural issues. The modified instrument includes questions about spirituality, ceremonial practices and use of hallucinogens, tribal support for recovery, and culturally specific living conditions and lifestyle. Part 1 presents the fifth edition ASI in its original format and describes how it was modified for Native Americans in North Dakota. A clinical/training version, contained in Part 3, has instructions, hints, and space for comments. Part 2 contains the North Dakota State Adaptation for Use With Native Americans, which is similar in format to the clinical/training version, and a revised users guide. (Contains 16 references.) (TD)

This paper discusses several models for treating chemical dependency in individuals who are deaf or hard of hearing. It begins by describing the 12-step model, a comprehensive, multi-disciplinary approach to the treatment of addiction which is abstinence oriented and based on the principles of Alcoholics Anonymous. This model includes group therapy, lectures, therapeutic work assignments, family counseling, and attendance at meetings. The next model profiled is the Cognitive Behavioral Treatment Model, a model based on cognitive therapy in which individuals learn how their thoughts, feelings, and behaviors are connected, and how to break those connections. The Bio-Psycho-Social Model is then described. This model is an experiential, peer oriented process that is based on the belief that alcohol problems stem from a lifetime socialization process in a particular social and cultural milieu that implicitly or explicitly encourages alcohol drinking. Using this model, the goal of treatment is improving the social functioning of substance abusers by either altering the social environment or altering the individual's coping responses to environmental stresses. Harm reduction is the final rehabilitation approach described. A case study is presented of a 29-year old deaf female with drinking problems. (CR)

Although the Internet offers information about psychological problems and support resources for behavioral health problems, the quality of this information varies widely. So as to offer guidance in this area, preferred sites pertaining to anxiety disorders, parenting problems, eating disorders, and chemical dependency were analyzed. A total of 365 web sites were evaluated, chosen randomly from the Internet. After reviewing the appropriate clinical literature for each of the problem areas being addressed, the nine raters assessed each site's potential as a psychological resource for those in need. After ratings were completed, raters selected the preferred sites. Three sites from each category are summarized here. The top sites for anxiety disorders exhibited various strengths, ranging from support ideas, to clarity, to evaluation, to encouragement. The three parenting sites were chosen due to their abundance of parenting resources and their many suggestions for obtaining further information. All three sites for eating disorders were rated as having the most complete coverage overall, providing comprehensive surveys of important topics within a search. The last category of sites, chemical dependency, offered a variety of services and information, including on-line 12-step meetings and user-friendly interfaces. (RJM)

The Internet provides a new means of obtaining psychological health care, but Internet site quality varies widely. To help in the search for reliable information in cyberspace, a ratings scale, which assesses six dimensions of site quality (accuracy, practicality, normalization, sense of belonging, referral, and feedback mechanisms) is offered here. Three hundred sixty-five web sites were evaluated on the 6 dimensions over an 11-week period on a 5-point scale. Descriptive information about the nature of the sources is supplied, allowing for comparisons of the relative quality of the available sites across the different content domains: anxiety disorders, parenting problems, eating disorders, and chemical dependency. Site ratings indicate that the availability of quality resources is associated with the prevalence of the problems being targeted. Common phenomena, such as parenting problems and chemical dependency, attract greater interest and resources for site development than do rarer conditions. Eating disorders are covered in a large number of high-quality sites, which may be attributable to the perception that this group of consumers is relatively affluent and well educated. Only 65% of sites could be re-accessed, indicating that marginal sites become abandoned, go out of business, or close for other reasons. Site surveys show that anxiety disorders sites feature subtle advertising of particular products, as do the chemical dependency sites. (RJM)

Experiential activities provide each participant with the ability to see, feel, and experience whatever therapeutic issue the facilitator is addressing, and usually much more. This paper presents experiential activities to address the 12 steps of recovery adopted from Alcoholics Anonymous. These 12 steps are used worldwide for many other recovery programs and substitutions are made, replacing the word alcoholism or alcoholic with addiction or addict. The 12 steps are presented, along with the principles behind them: honesty, hope, faith, courage, integrity, willingness, humility, brotherly love, discipline, perseverance, connection with God, and giving back to others. Experiential activities are described that promote reflection on and understanding of each of these principles. As a training exercise, these activities provide opportunities for participants to encounter the same kinds of feelings experienced by people in recovery in the course of working the 12 steps. (Author/TD)

The Yakima First Steps Mobilization Project for Pregnant Substance Abusers, known as First Steps PLUS, is a demonstration project. The project seeks to improve the health outcomes of pregnant substance abusing women and their infants by enhancing existing perinatal services provided through Washington's First Steps Maternity Care Program and by integrating and coordinating maternity care services with comprehensive substance abuse intervention services. This interim report summarizes development of the project components, describes their implementation, and analyzes the outcome data available to date. The report emphasizes process evaluation, especially related to: (1) the creation and county-wide implementation of a screening tool to access risk of substance abuse among women receiving Medicaid as one component of community mobilization; and (2) completion of the continuum of care for treatment of chemical dependency through improved availability of treatment options. Process measures are described from the beginning of the project in July 1993 through December 1995. Outcome measures are presented for births which occurred between July 1993 and December 1994. Demographic characteristics, risk factors, and birth outcomes are compared for Medicaid and non-Medicaid women residents of Yakima and for Medicaid women who were and were not screened for risk of substance abuse. Appendices include a First Steps PLUS screening form and the diagnosis codes used in identification of substance abuse in the First Steps Database. (WJC)

The first comprehensive assessment of substance abuse and women, this report arose from an analysis of more than 1,700 scientific and technical articles, surveys, government reports and books. Results show that American women are closing the gap with men in that they are increasingly likely to abuse substances at the same rate as men. Findings show that women are starting to smoke, drink, and use drugs at earlier ages than ever before. Unlike men, though, women get drunk faster, become addicted quicker, and develop substance abuse-related diseases sooner. Furthermore, at least one of every five pregnant women uses drugs, drinks, or smokes. An enormous gap exists between what experts know about women's substance abuse and what is known and acted on by women and those who care for them. It is recommended that women be made aware of the dangers of substance abuse. Prevention programs must address the reasons why women abuse substances and such programs must identify girls at highest risk. Health professionals, too, must recognize that women will manifest symptoms of substance abuse that are different from those of men, which may include a woman trying harder to hide her substance abuse due to intense shame. Contains approximately 750 references. (RJM)

There is evidence that drug treatment in correctional facilities can impact recidivism, perceptions of self-efficacy, and mood states such as depression and anxiety. This study was designed to provide detailed and systematic descriptions of participants and treatment program components for five drug treatment programs. Also included are program completion rates as well as 12-month postrelease outcome (recidivism) for program participants versus matched controls. Following a literature review on drug treatment in corrections, detailed process or program data for the five sites is presented. The next section discusses the various issues confronting treatment providers, and relevant policy considerations regarding the program approaches. It is concluded that these programs had modest positive effects on the probability but not the timing of recidivism (for those arrested and convicted) within one year of jail release. Minority offenders and younger offenders were less likely to be successful in the programs and had higher probabilities of recidivism. An appendix presents admission and exit forms used in the treatment programs. Forty-four tables and five figures present data and statistical analysis. Contains 45 references. (TS)

This study was designed to compare outcomes for two groups of alcohol and substance abuse clients (N=230): a control group assigned to regular 90 days of outpatient treatment, and an experimental group assigned to 180 days of extended outpatient care. Outcomes were compared in the following nine categories: (1) relapse, measured as reported alcohol or drug use subsequent to treatment; (2) post-treatment employment; (3) living arrangements; (4) medical and physical problems; (5) psychiatric problems; (6) legal or criminal justice system problems; (7) family and social relationships; (8) treatment re-entry; and (9) participation in 12-step or other support programs. The major focus of the study was to determine if the additional 90 days of outpatient treatment impacted post-treatment outcome. While the results of the primary analyses were not positive, the findings consistently suggest that extended outpatient treatment, regardless of whether it is the scheduled treatment received by both controls and experiments, or the unscheduled treatment received by either group, is associated with some positive outcomes. From the analyses of both the 90 and 180 days follow up surveys, there are few consistent findings on the impact of extended outpatient care for the nine client outcome areas studied. The principal conclusion is that overwhelmingly, there is no major difference between 90 day treatment or 180 day treatment. Eight appendices present statistical analyses and other materials related to the study. Contains 39 references. (TS)

A model of an integrated ecologically-based counseling and recovery program is explored as a means of incorporating educational and psychological nature-connecting methods and materials with traditional recovery activities for people at risk and as a preventative. The first part of the program introduces high-risk high school students, most of whom have low self-esteem, to elements of nature. The second part of the program focuses on reducing chemical use and irresponsible relationships in at risk students. Phase 1 of this part involved 3 weeks of play and creativity in natural settings. Phase 2 involves specially designed nature reconnecting activities to reduce stress and attune participants to nature. Phase 3 consists of a 5-day "ropes course" where students practice teamwork, use problem solving skills, and work on fear and stress reduction skills. The goal is to further reduce stress, and help them experience power, joy, and trust. Results of the project are overwhelmingly positive. Significantly increased scores on the Barksdale Self-Esteem Index are recorded. The results suggest that the project, used in conjunction with daily stress situations instead of artificially programmed stress activities, can serve as an ecologically sound citizenship education preventative for chemical, food, and social and environmental abuse. (KW)

This report describes a project intended to address specialized recruitment of a multiethnic drug and alcohol recovery population in Lycoming County, Pennsylvania, who had not availed themselves of adult literacy services. A collaborator would be established within the community to encourage educationally disadvantaged adults who would be supported by their peers to seek educational services. Tutors and students were recruited and received instruction via one-on-one tutoring or small group tutorial. A small group tutorial training package was developed. The five-page report is accompanied by the training package. It provides these components for each of the eight areas covered in the two training sessions: objectives, materials list, rationale, and procedures. The eight areas are as follows: introductions, you the tutor, the adult learner, the reading process, the writing process, opportunistic teaching/learning, phonics and decoding skills, and wrap-up and evaluation. Student handouts are provided. (YLB)

The 43 million Americans with disabilities comprise the largest minority group in the United States. While their special abilities may vary considerably, these Americans share an increased risk for alcohol and other drug abuse. This study concentrates on the deaf community and the general lack of awareness of the problem of substance abuse within that population. Examined in this research were a variety of predictor variables, such as deafness characteristics, demographics, and treatment readiness indicators. Researchers tried to determine the influence of these variables on desired treatment outcomes among 100 Deaf and Hard of Hearing persons who had completed a chemical dependency treatment program. The tests incorporated for the study were using independent and dependent variables with special emphasis on follow-up information gathered on a 1, 3, 6, and 12 month basis. Twelve general recommendations for the treatment of deaf and hard of hearing individuals were developed. These included making vocational rehabilitation a strong component of inpatient treatment and of aftercare, developing a curriculum that focuses on the importance of employment and teaches some basic skills related to how to seek, access, and retain employment, and establishing training programs for vocational rehabilitation counselors and other workers who serve the deaf and hard of hearing community. Eleven bar graphs present data. Contains 35 references. (RJM)

When assessing quality of life satisfaction in relation to an individual's recovery from an addiction, such as alcoholism, the expressed need for spiritual well-being is frequently a significant aspect of the psychotherapeutic encounter. Some of the quantitative and qualitative aspects of spiritual well-being in recovering alcoholics are examined. The study was guided by the following questions: What is a satisfactory measure for spiritual well-being? How could such a measure be useful not only for research but for psychotherapeutic use? How might such a measure and its findings be adapted to working with addicted clients? and How do the reports of spiritual well-being of addicted individuals compare to a similar group of nonaddicted adults? After reviewing the research addressing these issues, the study designed to answer these questions is described. The study sample of 58 non-alcoholics and 50 alcoholics were administered the Spiritual Well-Being Scale (SWB). The SWB consists of an Existential Well-Being Scale (EWB) and a Religious Well-Being Scale (RWB). Findings indicate that the nonaddicted group scored significantly higher on the total SWB and the EWB scales, suggesting that life circumstances related to addiction and alcoholism negatively influence individuals' spiritual well-being. Results were analyzed qualitatively by interviewing recovering alcoholics on their spiritual development path. A model describing this path is presented with narrative descriptions provided by subjects in various points of their recovery. (RJM)

This report provides a cost-benefit analysis of a program that provides publicly-funded treatment and support for persons who are addicted to alcohol or other drugs and who are judged to be indigent, unemployable, and incapacitated due to their addiction. The study focused on two client outcomes: (1) determine employment outcomes during an 18 month follow-up period; and (2) analyze whether public service costs incurred by treated clients decreased after treatment, giving rise to a potential cost-avoidance effect of public investment in chemical dependency treatment. Data were derived from clients' case records and from persons eligible for the program but who received no treatment. Some of the key findings included positive employment outcomes in which more clients became substantively and continually employed after treatment than did non-clients--even more gained jobs after extra vocational training; a favorable cost avoidance effect of treatment for a majority of clients, with the cost avoidance impact of treatment being largest among younger clients and among clients without mental health problems; and a mortality rate among regular clients that was 5.7 times higher than the general population of the same age and gender. Seven appendices supply methods and statistical models. Contains 38 references. (RJM)

The Task Group on Gender-Focused Research was established to raise awareness and interest in gender as a variable in addictions research at the Addiction Research Foundation (ARF) in Ontario (Canada). Recognizing that much of the research on substance abuse has focused on males, the Task Group was charged with providing a basis for the development of research and program plans related to gender issues, and operated under a dual mandate: (1) consider the needs and opportunities in gender-focused research within the scope of ARF's purpose, including, but not limited to, research on alcohol, tobacco, and other drug use and problems in female populations; and (2) examine the relative priority of different lines of research for ARF. The investigation into gender biases in existing research revealed a strong male focus in research. Some ways suggested to correct this slant include using research samples that include both sexes, studying women specifically, and not generalizing results to both sexes with a unisexual sample. For the topic of gender issues in selected areas of research, an examination was made of epidemiology, including patterns of use and the health and social consequences of use; gender roles and interactions; prevention; biological research; and treatment modalities and treatment systems. Each section of the report profiles opportunities for research at ARF and recommendations on gender-based research and research methodology at ARF are elaborated at the conclusion. Four appendices list research questions, current policies on gender research, and other information. (Contains 87 references.) (RJM)

The American Institute for Learning (AIL) has developed two interactive multimedia drug-awareness programs for secondary students who have used substances experimentally or are being challenged by others to experiment with drugs. The first, "Addiction and Its Processes," is an awareness program with video and computer capabilities and an informational database. The second, "Life Moves: The Process of Recovery," follows the first year of recovery through a video with graphical and database information. AIL evaluated the addiction program in 1992 at 7 locations with 44 students and again a year later in 5 facilities with 35 students. Student data included information pretests and posttests, attitudinal questionnaires, and interviews. Perceptions of site facilitators were also gathered. Data indicate that the videos are a valuable way to teach young people about addiction and recovery. The power of video can pull students into the program, but these programs can be weakened by too many other instructional options. The addiction video was more compelling because it was allowed to carry the programs. Evaluation results were used to revise both programs. (Contains 5 references.) (SLD)

In January of 1994 the Addictions Training Center at the University of Nevada, Reno surveyed the treatment staff and directors at 46 publicly supported addictions training centers located in the state of Nevada. Four hundred twenty-nine surveys were mailed, and 189 were returned. In addition to demographic information, respondents were surveyed on education and training, licensure, treatment setting, knowledge, ability, and interest in training in 47 areas. It was discovered that over 40% of respondents who identified themselves as counselors and therapists did not possess the baccalaureate degree. Thirty-one percent had obtained the master's degree or higher. Recommendations are made for the Addictions Training Center to offer programs in counseling skills for individuals, groups and families, and in treatment planning issues. (Author)

Although the question of priority training needs for workers in British Columbia's (Canada) Alcohol and Drug Programs (ADP) direct service and funded agencies has been examined in the past, no prior needs assessment systematically surveyed workers in all job categories throughout the province. Results were obtained for administrators, program supervisors, health care workers, counselors, prevention workers, and office support workers. Respondents (n=149) completed a questionnaire which asked them to identify the tasks they performed in the domains of assessment, counseling, case management, education, and professional responsibility. Priority training needs were then determined for each group. The project team then examined the knowledge and skill components of those tasks for which at least one group identified a priority training need, and organized those components into educationally meaningful topic groupings. Respondents were a relatively educated group, with about three-quarters possessing at least a college certificate. Respondents were primarily concerned that training be accessible, pertinent and credible, and offered a wide range of recommendations. Contains 16 references. Appendices include the Questionnaire, Summary of Respondents' Self-ratings on Performance of Job Requirements, Component Analysis of Tasks Identified as High Priority Training Needs, and Focus Group Report. (JBJ)